Comparative Study of IVF Policy and Practice in the United States and Israel

Hello Readers! This is the first in a four part series investigating the policy behind and practice of IVF technology in United States and Israel. This month’s post will discuss the development and current state of official government policies regarding the technology’s coverage or lack thereof.

Societal norms regarding gender roles influence a society’s perspective on the importance of reproduction. In comparing the United States and Israel, intrinsically different cultural tenets have lead to drastically different policies regarding in vitro fertilization treatment (IVF).

An interesting question to explore is “which demographics are actually using the technology in each nation?” While Israel promotes procreation, the United States promotes productivity in a more economic sense. Though this may lead one to believe that older women are using IVF in the United States and younger women in Israel, this is surprisingly not the case. The average age of IVF users has increased in Israel and remained constant in the United States.

Today’s post will delineate the history of IVF regulation. In the next two segments of the series, we will look at potential cultural values that have led to the development of each policy and perform an analysis of age demographics for each country. Finally, we will close the series by conducting an inspection of fertility clinic advertisements to explore how policy and societal norms influence the target consumers of IVF and how gender scripts change in the face of varying access to the procedure.

The development of IVF is a relatively recent affair, as the first baby conceived through this procedure was born in 1978 in England. Patients may seek IVF treatment for a variety of reasons, a few stemming from fallopian tube abnormalities, ovulation dysfunction, diminished ovarian reserve, endometriosis, or sperm defects. Originally designed for women who had blocked or missing fallopian tubes, the procedure is able to remove the process of conception outside of the body. The woman’s eggs are extracted from her body and fertilized with the man’s sperm in a laboratory for a few days before being inserted into the uterus.

The first baby born from IVF in the United States was Elizabeth Carr in 1981, under the direction of the physician team of Howard and Georgeanna Jones. The United States government has had a complex relationship regarding IVF regulation from the very beginning, ultimately resulting in the government’s preferred position of simply engaging as little as possible in the process. Ironically, IVF is the only medical procedure for which success rate reporting is federally mandated. During the early phase of IVF research, the Institutional Review Board (IRB) system, used today to regulate research on human subjects, did not exist. In 1973, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was founded, and was responsible for delineating “ethical guidelines and rules for research projects on embryos or fetuses submitted for consideration for federal funding.” The committee proposed that an “Ethics Advisory Board” approve any projects regarding test tube conception in order to receive federal funding, but the board was never instituted, essentially creating a ban on federal funding for this type of research for several years. In 1977, a board was finally established, but its report two years later failed to provide clarity on the issue. They wrote that the procedure was “ethically defensible, though still legitimately controverted” and that “there were compelling reasons to proceed with it under limited circumstances.” This effectively postponed any decisions regarding funding. Ethical discussions regarding IVF soon came to focus on the moral status of the embryo, a debate that continues to this day.

The federal government’s pattern of “non-policies” that did not directly inhibit the development of IVF inadvertently led to the technology’s advancement. From the very beginning of IVF research, IVF was entrenched in the national conflict of abortion. Opponents of abortion argued that IVF involved the intentional destruction of embryos, and this connection helped facilitate the government’s hesitation in staunchly regulating the procedure. Pro-life opposition unintentionally provided the financial and human intellectual resources needed to promote IVF technological development, as a complex libel suit stemming from anti-abortion protestors resulted in the financing of the Joneses’ research. Additionally, one of the NIH’s most promising reproductive scientists, Gary Hodgen, left the NIH to join the Jones Institute because he felt that the influence of pro-life lobbies on federal agencies was stifling his scientific progress.

By the mid-1980s, IVF became a commonplace procedure in the Unites States. In the 80s, the Republican Party controlled the White House, and anti-abortion forces prevented federal agencies from making any policy progress regarding embryo research. Instead of regulating the practice of the actual procedure, agencies simply legislated IVF through consumer protection laws. For instance, the Wyden Bill in 1992, mandated IVF clinic success rate reporting and provided IVF clinic data for free to prospective patients. Federal legislation has remained relatively unchanged since this bill, with the only additions being the stem cell research developments under the Bush administration that further imbedded IVF in the abortion debate and prohibited the use of newly created embryonic stem cell lines in research.

Currently, most regulation concerning IVF comes from internal professional agencies. The federal government only “requires laboratories engaged in assisted reproduction to be certified by organizations such as the American College of Pathologists and to report certain data to the CDC.” No government organization regulates “how many children may be conceived from one donor, what types of medical information or updates must be supplied by donors, which genetic tests may be performed on embryos, how many fertilized eggs may be placed in a woman or how old a donor can be.” Most regulation comes from the American Society for Reproductive Medicine, which issues guidelines to its membership, but does not punish those who deviate from the guidelines. Market forces have driven access, since those who can afford the procedure are those who can most readily obtain it.

Only five states have instituted unique insurance policies that increase access by issuing mandatory coverage for IVF procedures under delineated guidelines. Connecticut requires individual and group health insurance policies to cover medically necessary expenses for infertility diagnosis and treatment for a life-time maximum of two cycles of IVF for women under the age of 40. Illinois requires group insurance to cover four rounds of IVF, except if a live birth follows a completed oocyte retrieval, then two more completed oocyte retrievals are covered. Massachusetts law states that “general insurance policies, non-profit hospital service corporations, medical service corporations and health maintenance organizations that provide pregnancy-related benefits to also provide coverage for the diagnosis and treatment of infertility, including in vitro fertilization.” In New Jersey, IVF is covered for a maximum of four cycles as long as the patient has “used all reasonable, less expensive and medically appropriate treatments and is still unable to get pregnant or carry a pregnancy” and is 45 years old or younger. Rhode Island law states that “any contract, plan or policy of health insurance (individual and group), nonprofit hospital service, nonprofit medical service and health maintenance organization to provide coverage for medically necessary expenses for the diagnosis and treatment of infertility” and “ co-payments for infertility services not exceed 20 percent.” The United States federal government has essentially displaced the issue of IVF regulation to professional organizations and the issue of coverage and access to state governments, deciding that overseeing the procedure would be too complicated given its relationship to moral issues such as abortion, which continues to be a national debate.

In comparison to the United States, policies surrounding IVF in Israel are much simpler. Unlike in the Unites States, the progress of IVF in Israel was cast in a solely positive light, “welcomed by the press as a technological breakthrough.” The procedure was idealized and romanticized, and lacked the initial moral ambiguity that plagued the practice in the United States. The tone used to present the development of the technique defined it as a solution for “sterility” and categorized the patient population as those who were suffering from a “disease,” to which now there was a cure in the form of IVF.

Israel has had a national healthcare system since 1995, that requires all citizens to belong to one of four health-care organizations. The government subsidizes the health insurers in correlation to their membership size, and each provides a standardized basket of services. IVF treatment is a covered service for all citizens and can be used “for the purpose of the birth of two children for couples who do not have children from their present marriage, as well as for childless women who wish to establish a single-parent family.” Until 2014 when revisions were instituted to the national health insurance policy, funding was essentially unlimited for women between the ages of 18 and 45 years old for fertility treatments. There was no maximum number of cycles a woman could have of IVF, since the limiting factor was the number of children she has with the current partner (or by herself in the case of single mothers). In 2014, the ministry of health instituted some regulations regarding the number of cycles a woman could receive. The changes stated that women over the age of 42 would only be allowed to undergo a maximum of “three consecutive IVF treatments in which they did not reach the embryo returning stage during the treatment (if embryos are returned, even in the third cycle, the count starts again)” and that for any age “after 4 consecutive months of treatment” or “after 8 IVF cycles” patients would have to have a discussion with their physician team and a social worker to decide if additional cycles should be pursued.

Next month, come back to read about the social dynamics in each nation that may be driving the coverage practices described today!

Sources:

Birenbaum-Carmeli, Daphna, and Martha Dirnfeld. “In Vitro Fertilisation Policy in Israel and Women’s Perspectives: The More the Better?” Reproductive Health Matters, vol. 16, no. 31, 2008, pp. 182–191. www.jstor.org/stable/25475378.

Harris, Lisa Hope. Challenging conception: A clinical and cultural history of in vitro fertilization in the United States. University of Michigan Diss. Univeristy of Michigan, 2006. Web. 29 Nov. 2016.

“Infertility FAQs.” Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 14 Apr. 2016, www.cdc.gov/reproductivehealth/infertility/#14.

“IVF – In Vitro Fertilization.” Ministry of Health, State of Israel, June 2014, www.health.gov.il/English/Topics/fertility/Pages/ivf.aspx.

Levush, Ruth. “Israel: Reproduction and Abortion: Law and Policy.” The Law Library of Congress, Global Legal Research Center, Feb. 2012, www.loc.gov/law/help/il-reproduction-and-abortion/israel-reproduction-and-abortion.pdf.

Ollove, Michael. “Lightly Regulated in Vitro Fertilization Yields Thousands of Babies Annually.” The Washington Post, WP Company, 13 Apr. 2015, www.washingtonpost.com/national/health-science/lightly-regulated-in-vitro-fertilization-yields-thousands-of-babies-annually/2015/04/13/f1f3fa36-d8a2-11e4-8103-fa84725dbf9d_story.html?utm_term=.c39d5bb2ee2b.

“National Health Insurance.” Israel Ministry of Foreign Affairs, State of Israel, 1 Sept. 1995, www.mfa.gov.il/mfa/mfa-archive/1990-1995/pages/national%20health%20insurance.aspx.

“State Infertility Insurance Laws.” American Society for Reproductive Medicine, American Society for Reproductive Medicine, 2016, www.asrm.org/insurance.aspx.

“State Laws Related to Insurance Coverage for Infertility Treatment.” National Conference of State Legislatures, National Conference of State Legislatures, 1 June 2014, www.ncsl.org/research/health/insurance-coverage-for-infertility-laws.aspx.

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